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Summary: The current benchmark for tongue reconstruction after excision of locally advanced tumors involves the use of free skin or fasciocutaneous flaps, such as the anterolateral thigh flap or forearm free flap. They facilitate the volumetric reconstruction of the tongue, leveraging passive mobility from the remaining native tongue tissue. The challenge in tongue reconstruction surgery remains achieving functional restoration through adequate volume and optimized mobility, using tissue that is both adapted and comparable to native tissue. Although the free serratus muscle flap has been described for various indications, its application in tongue reconstructions remains underexploited. In cases of locally advanced tumors affecting the mobile tongue, typically within the junctional area and without extension to the floor of the mouth or to the tip of the tongue, the serratus free flap has shown positive results. Reinnervation of the flap is achieved connecting the thoracodorsal nerve to the descending branch of the XII nerve. This technique facilitates functional tongue reconstruction, promoting rapid mucosal epithelialization and reinnervation, which, in turn, preserves muscle volume and sustains adequate trophicity without fibrosis. Regarding these considerations, the pure muscle serratus free flap emerges as a valuable and effective alternative in tongue reconstruction. There is a dearth of step-by-step operative technique descriptions for this indication in the literature. The authors present videos demonstrating the surgical technique, showcasing procedures as performed at Tenon Hospital (Paris, France)., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Purpose: This study aimed to define a new surgical method using a neurotized platysma free flap to provide dynamic reanimation, enhanced functional recovery, and low morbidity for blepharoptosis repair., Methods: Ten hemifaces and neck halves of five formalin-fixed cadavers were included in the study. The origin of the neurovascular structures of the pedicle was identified at the submandibular triangle. A 5 × 3 cm platysma flap was dissected. For the recipient side, the main donor vascular structures were observed at the frontal part of the temporal region. The diameters of the donor structures were measured with a digital Vernier caliper. The statistical analysis of the study was performed with Jamovi statistical software version 2.3.36. P < 0.05 was accepted as a statistically significant value., Results: At the donor region, the pedicle included branches of the cervical branch of the facial nerve and the facial artery in all specimens. However, the venous graft pedicle origin could be either the facial vein or the lingual vein. At the recipient region, the mean diameters of the most anterior nerves, arteries, and veins were 1, 2.03, and 2.37 mm respectively. In a side comparison of pedicle variables, only pedicle artery diameter and lateral palpebral commissure-anterior superior point of auricula distance had statistically significant differences between hemifaces., Conclusion: A 5 × 3 cm size platysma flap located in the submandibular trigone would be a good choice for functional blepharoptosis surgery. The thin structure and the appropriate neurovascular pedicle structure should enable performing a successful flap transfer., Competing Interests: Declarations. Ethical approval: This study was conducted in accordance with ethical guidelines for research and publication. In our universities, ethical approval is not required for scientific studies involving cadavers or cadaveric body parts. The authors sincerely thank to those who donated their bodies to science, enabling this anatomical research. The findings from such research can contribute to the advancement of medical knowledge, ultimately enhancing patient care. Therefore, the donors and their families deserve our utmost appreciation and respect. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose of Review: This review highlights recent advances in facial reanimation surgery particularly related to muscle transposition and free functional muscle transfer (FFMT)., Recent Findings: FFMT and muscle transposition are mainstays in the treatment of chronic facial paralysis. Recent literature evaluates single versus dual innervated FFMT, reanimation of the periocular region and lower lip depressors, and indications for such methods over gold standard FFMT techniques. New donor sites for muscle transposition and FFMT are also described., Summary: Gracilis FFMT (GFMT) continues to be the gold standard in dynamic facial reanimation for patients with chronic facial paralysis. Muscle transposition should be considered in older patients, those medically unfit for long operative procedures, and individuals who prefer more immediate results. With respect to FFMT, described nerve coaptation patterns, surgical stages, and donor muscle choice vary. Standardization of data reporting and outcome measures is needed in future studies., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background:  In facial reanimation, dual-innervated gracilis free functional muscle transfers (FFMTs) may have amalgamated increases in tone, excursion, synchroneity, and potentially spontaneity when compared with single innervation. The ideal staging of dual-innervated gracilis FFMTs has not been investigated. We aim to compare objective long-term outcomes following one- and two-stage dual-innervated gracilis FFMTs., Methods:  Included were adult patients with facial paralysis who underwent either one- (one-stage group) or two-stage (two-stage group) dual-innervated gracilis FFMT with ≥1 year of postoperative follow-up. Facial measurements were obtained from standardized photographs of patients in repose, closed-mouth smile, and open-mouth smile taken preoperatively, 1 year postoperatively, and 3 years postoperatively. Symmetry was calculated from the absolute difference between the paralyzed and healthy hemiface; a lower value indicates greater symmetry., Results:  Of 553 facial paralysis patients, 14 were included. Five and nine patients were in the one- and two-stage groups, with mean follow-up time, respectively, being 2.5 and 2.6 years. Within-group analysis of both groups, most paralyzed-side and symmetry measurements significantly improved over time with maintained significance at 3 years postoperatively in closed and open-mouth smile (all p ≤ 0.05). However, only the two-stage group had maintained significance in improvements at 3 years postoperatively in paralyzed-side and symmetry measurements in repose with commissure position (median change [interquartile range, IQR], 7.62 [6.00-10.56] mm), commissure angle (median change [IQR], 8.92 [6.18-13.69] degrees), commissure position symmetry (median change [IQR], -5.18 [-10.48 to -1.80] mm), commissure angle symmetry (median change [IQR], -9.78 [-11.73 to -7.32] degrees), and commissure height deviation (median change [IQR], -5.70 [-7.19 to -1.64] mm; all p ≤ 0.05). In the between-group analysis, all measurements were comparable in repose, closed-mouth smile, and open-mouth smile (all p  > 0.05)., Conclusion:  Long-term outcomes demonstrate that both one- and two-stage dual-innervated gracilis FFMTs significantly improve excursion, but only two-stage reconstruction significantly improves resting tone., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: The purpose of this study was to compare long-term tone and excursion in single- versus dual-innervated free functional muscle transfer (FFMT) in patients with longstanding facial paralysis., Methods: Patients with longstanding facial palsy treated with an FFMT innervated either by a nerve-to-masseter graft (single-innervation group) or nerve-to-masseter and cross-facial-nerve grafts (dual-innervation group) were included. One-year minimum follow-up was required. Outcome measures, based on standardized photographs, included excursion, smile angle, teeth exposure, commissure height deviation, and upper lip height deviation in repose and in closed and open-teeth smile preoperatively and at 3 months, 1 year, and 3 years postoperatively. Emotrics software and ImageJ software were used to take measurements. Between-group and within-group longitudinal comparisons were analyzed., Results: At 3 years (single, n = 24; dual, n = 13), significance was found between groups in commissure position (single, 26.42 mm versus dual, 31.51 mm; P < 0.0001) and excursion with open-mouth smile (single, 31.32 mm versus dual, 26.59 mm; P < 0.001). Single-innervation FFMT within-group analysis lacked significant improvement in commissure height deviation and upper lip height deviation at 3 years in repose, whereas the dual-innervation group revealed significant improvements (3.67 mm [ P < 0.001], 3.17 mm [ P < 0.001], respectively). Teeth exposure revealed an increase in the dual-innervation group (single, 35.753 mm 2 versus dual, 64.177 mm 2 ), but significance was not observed., Conclusion: Dual-innervated FFMT revealed improvements in resting tone and teeth exposure with minimal decrease in smile excursion compared with single-innervated FFMT., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: This work aimed to investigate the change in fingerprint depth and the recovery rule of fingerprint biological recognition function after repairing finger abdominal defects and rebuilding fingerprint with a free flap., Method: From April 2018 to March 2023, we collected a total of 43 cases of repairing finger pulp defects using the free flap of the fibular side of the great toe with the digital nerve. After surgery, irregular follow-up visits were conducted to observe fingerprint clarity, perform the ninhydrin test or detect visible sweating with the naked eye. We recorded fingerprint clarity, nail shape, two-point discrimination, cold perception, warm perception and fingerprint recognition using smartphones. The reconstruction process of the repaired finger was recorded to understand the changes in various observation indicators and their relationship with the depth of the fingerprint. The correlation between fingerprint depth and neural repair was determined, and the process of fingerprint biological recognition function repair was elucidated., Result: All flaps survived, and we observed various manifestations in different stages of nerve recovery. The reconstructed fingerprint had a clear fuzzy process, and the depth changes of the fingerprint were consistent with the changes in the biological recognition function curve., Conclusion: The free flap with the digital nerve is used to repair finger pulp defects. The reconstructed fingerprint has a biological recognition function, and the depth of the fingerprint is correlated with the process of nerve repair. The fingerprint morphology has a dynamic recovery process, and it can reach a stable state after 6-8 months., (© 2024. The Author(s).)

Purpose: In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios., Methods: A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis)., Results: Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12-72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1 patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4., Conclusions: A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves., Type of Study/level of Evidence: Therapeutic V., (Copyright © 2023. Published by Elsevier Inc.)

Facial paralysis (FP) is a devastating condition that can lead to significant aesthetic, social, and emotional morbidities for patients. For some patients with FP, free gracilis muscle transfer (FGMT) is the best option for smile restoration. Masseteric-driven FGMT produces a reliable voluntary smile. Cross-face nerve graft-driven FGMT can produce a spontaneous smile, but this technique has higher failure rates. Early studies suggest dual-innervation FGMT can produce a spontaneous smile while maintaining the reliability of masseteric-driven procedures. Great care should be taken during FGMT surgery to minimize facial bulk and place medial inset sutures that create a natural-appearing smile., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Breast reconstruction often renders the chest skin and nipple areolar complex (NAC) insensate. We propose a new technique of preserving the intercostal nerves during mastectomy and using them to reinnervate the NAC following mastectomy and immediate autologous tissue reconstruction. The technique involves preservation of the lateral intercostal nerves during mastectomy, dissection of the lateral intercostal nerves to length, coaptation of the intercostal nerves to a nerve graft which is then tunneled through the free flap and the distal nerve graft is then coapted to the nerve stumps at the base of the NAC. We performed a retrospective analysis of 14 breasts, which underwent nipple reinnervation during immediate autologous breast reconstruction. Mean age was 49 years (range: 32-61 years). Sensory outcomes, as tested with Semmes-Weinstein monofilaments, were compared to a cohort of breasts that underwent nipple sparing mastectomy without neurotization. Compared to control patients, there was no statistically significant difference (p = 0.0969) in sensation between pre-operative and post-operative nipple sensation at final follow-up. This proof-of-concept study suggests that immediate re-innervation of the NAC in the setting of immediate breast reconstruction enhances recovery of the NAC sensation., Competing Interests: Declaration of Competing Interest The authors do not have any conflict of interest to declare., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The posterior aspect of the leg is an ideal donor site for flap surgery. In this study, the anatomy was investigated of the lateral sural cutaneous nerve (LSCN) and its accompanying artery, superficial lateral sural artery (SLSA), and a lateral sural neurocutaneous flap was designed., Methods: Five fresh adult cadaver legs perfused with red latex were dissected to observe the course and relationship between LSCN and SLSA. The outer diameter of SLSA at its origin was measured. Then a lateral sural neurocutaneous flap was designed and used to repair soft tissue defects in six patients., Results: The anatomic results showed that the SLSA gave rise to branches that followed the LSCN and ramified into terminals at the ramification of the nerve. It originated directly from the popliteal artery 4.2 ± 0.2 mm above the fibular head, where its outer diameter was 0.96 ± 0.23 mm. Several perforators penetrated from the crural fascia and anastomosed to the SLSA, creating a fine anastomotic network. The clinical results showed that the size of the flap ranged from 12 × 6 cm to 25 × 8 cm. All six flaps survived completely without complications. Follow-up ranged from 6 to 18 months with 11 months on average. The overall contour and sensory recovery of the flap were satisfied., Conclusion: A free innervated flap may be elevated safely based on the LSCN and its accompanying vessels. It provides an alternative in reconstruction of soft tissue defects where sensory recovery is important.

Competing Interests: Declaration of Competing Interest n/a.

Microneurovascular free muscle transfer is the gold-standard surgical procedure for the reanimation of established facial paralysis. However, the innervation of the transferred muscle by the contralateral facial nerve is usually insufficient to produce a stable smile. Besides, the corner of the mouth sometimes moves unnaturally as if it were being pulled up because of the single-direction movement. Thus, we propose one-stage facial reanimation using free latissimus dorsi (LD)-serratus anterior (SA) combined muscle flap transfer with dual innervation. The LD-SA combined muscle flap was harvested with the thoracodorsal artery and vein as common vessels to move the corner of the mouth bidirectionally for natural smiling. The LD muscle was located in the same direction as the zygomaticus major muscle and reinnervated by dual innervation. The contralateral facial nerve was coapted with the thoracodorsal nerve, and the ipsilateral masseter motor nerve was inserted into the LD muscle by intramuscular neurotization. The 6th or 7th SA muscle was located in the same direction as the risorius muscle and reinnervated by neurorrhaphy of the long thoracic nerve and the thin branch of the ipsilateral masseter motor nerve. Since 2015, seven patients have been treated with this method without complications. On average, SA muscle movement was detected in voluntary biting at 3.1 months, and spontaneous smiling occurred 7.7 months after surgery. All patients developed a spontaneous natural smile. This method for established facial paralysis has the potential to improve the quality of the reconstructed smile and the unstable results of conventional single-innervation-single-muscle transfer., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: This prospective study was performed to investigate the distribution of proximal ulnar artery perforating vessels through three-dimensional blood vessel reconstruction and examine the presence and consistency of the perforating vessels intraoperatively., Methods: For anatomical guidance, three-dimensional blood vessel reconstruction was performed to determine the consistent presence of perforating vessels in the proximal ulnar artery. A free proximal ulnar artery perforator flap was then transferred in 17 patients to resurface skin defects on the hands. Color Doppler ultrasound was used to identify and mark the perforating vessels. Intraoperative evaluation was conducted to check for anastomosis of the perforating vessels at the marked sites and assess the vessel anastomosis conditions., Results: No vascular crisis, flap necrosis, or wound infection occurred after surgery in 15 patients. Postoperative follow-up was conducted for 6 to 36 months. The appearance of the flap was satisfactory, the texture of the flap was soft, sensation was well restored, and hand function was not limited. The mean two-point discrimination of the flap was 7.6 ± 2.2 mm., Conclusions: Free sensory proximal ulnar artery perforator flap transfer is a safe and reliable surgical technique with respect to restoration of both the appearance and sensory function of the hand.

Recent attempts have been made to direct the sensory neurotisation of free superficial circumflex iliac artery (SCIA) flaps. However, donor nerves enabling sensory recovery are limited. We report our findings in fifteen patients who underwent distal limb defect reconstruction using a sensate SCIA flap, including the lateral cutaneous branch of the subcostal nerve (LCSN), between August 2017 and September 2018. The distance from the anterosuperior iliac spine to the point where the LCSN crossed the iliac crest ranged between 6.5 and 10 cm. The diameter ranged between 1.5 and 4.0 mm. The flap size ranged between 8 × 4 and 13 × 10 cm 2 . All of the flaps survived uneventfully. Tests of sensory modalities, including the Semmes-Weinstein (SW) touch, vibration, pinprick, temperature and static two-point discrimination (s2PD) tests were applied in nine regions of each flap post-operatively. One or more modalities were present in at least one region at 6 months post-operatively, and the recovery of vibration perception was more consistent than that of SW touch and pinprick perception. The recovery of s2PD was noted in 4 cases over a follow-up period of more than 12 months. A reliable sensate flap with the LCSN can be considered as an attractive option for the sensory reconstruction of distal limb defects of moderate size., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare in relation to the content of this article., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background:  Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer., Methods:  A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization., Results:  A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common., Conclusion:  Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps., Competing Interests: K.R.E. is a consultant for AxoGen and Integra. The other authors have no financial interests in any of the products or techniques mentioned and have received no external support related to this study., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background/aim: Large full thickness abdominal wall defects following malignancies can be a reconstructive challenge. The purpose of this study was to analyze long-term outcomes and complications following abdominal wall reconstruction using composite antero-lateral thigh (ALT) flaps., Patients and Methods: The study retrospectively investigated 16 consecutive patients who underwent abdominal wall reconstruction with autologous flap between May 2003 and March 2018. Volumetric flap analysis was used to assess flap atrophy over time, evaluating the role of denervation and reinnervation. The long-term outcome was assessed to compare the two groups (free vs. pedicled ALT flap reconstructions)., Results: All flaps successfully covered the defects. We found a significant increase in flap resorption in free flaps when compared to pedicled ones. Abdominal bulging was seen in 3 out of 16 (19%) patients after more than 12 months follow-up, in close correlation with mesh absence., Conclusion: Free flaps were shown to be equally effective as their pedicled counterparts, without significant increase in complication rate., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Purpose: Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed, or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice. In this report, the authors present the results of a comparison study on different donor nerves (spinal accessory and ulnar) in elbow flexion reconstruction with gracilis flap for traumatic adult brachial plexus injuries., Methods: Retrospective analysis of patients with both total or partial traumatic brachial plexus injuries was carried out. Of the 38 patients enrolled, 37 were male (97.4%) with a mean age of 28.3 years. The mean follow-up period was 25 months. Postoperative function of the gracilis muscle flap was recorded and patients were divided into two groups according to donor nerve: spinal accessory nerve (SAN) (18 cases), and motor fascicles of the ulnar (ULNAR) (20 cases)., Results: Twenty-six cases obtained elbow flexion strength M3 or M4 (68.4%): 0 M0 (0.0%), 4 M1 (10.5%), 8 M2 (21.1%), 9 M3 (23.7%) and 17 M4 (44.7%). The mean interval to first recorded M3 muscular strength was 12.4 months. Functional elbow flexion strength (≥ M3) had the following distribution: SAN 83.3% (15/18) and ULNAR 55.0% (11/20) (p = .086)., Conclusion: No statistical difference for final muscle strength was found between donor nerve groups., (© 2019 Wiley Periodicals, Inc.)

Background: We evaluated the time course and differences in the sensory recovery of three commonly used free flaps for lower extremity reconstruction. Furthermore, the sensory recovery of skin-grafted muscle and skin paddle in latissimus dorsi flaps (LDMF) were differentiated., Methods: In a prospective study, 26 patients who had undergone free flap lower extremity reconstruction were enrolled. Among them, 9 received LDMF, 9 received gracilis muscle flaps (GMF), and 8 received anterior lateral thigh flaps (ALTF). The sensory recovery was investigated by using the Semmes-Weinstein test (SWT) at 6 and 12 months after the surgery., Results: All flaps recorded spontaneous sensory recovery. The GMF showed the smallest anesthetic area after 12 months as compared with the ALTF and LDMF (1 ± 3% vs. 18 ± 39% (p < .05) vs. 35 ± 35% (p < .05), respectively). Qualitatively, ALTF exhibited the best sensory recovery with the lowest SWT values (ALTF 4.57 ± 1.12 vs. GMF 5.01 ± 0.81 8 [p < .05], vs. LDMF 5.84 ± 0.52 [p < .05]). The sensory recovery of skin-grafted muscle was superior to that of the skin paddle in the LDMF (anesthetic area 29 ± 36% vs. 54 ± 33% [p < .05], SWT 5.85 ± 0.60 vs. 6.30 ± 0.18 [p < .05], respectively)., Conclusion: All flaps displayed spontaneous sensory recovery potential over the investigation period, which appeared to be influenced by the flap type and size. The LDMF skin paddle showed lower potential for sensory recovery as compared with the skin-grafted muscle area of the same flap. The GMF demonstrated a near-complete sensory recovery after 12 months., (© 2018 Wiley Periodicals, Inc.)

Purpose: To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis., Methods: Twenty-four male patients were reoperated upon an average of 45 months (SD, ± 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle belly was sutured to the biceps distal tendon. Vascular repair was performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus., Results: Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110° (95% confidence interval [95% CI], 100°-120°) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94° (95% CI, 86°-102°). There was, on average, a 10° (95% CI, 4.4°-15.6°). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in 12., Conclusions: In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

A frequently encountered anatomical structure in the elevation of a radial forearm free flap is the superficial branch of the radial nerve. This structure has a relatively consistent anatomic location, but variations do occur. We present a case where the superficial branch of the radial nerve was in an usual position but remained superficial to the brachioradialis throughout its course. Two previous reports also describe the superficial branch of the radial nerve remaining superficial to the brachioradialis, although, in these reports, the nerve was more medial than is typical. We postulate that one of the most common anatomic variations of the superficial branch of the radial nerve is for it to remain superficial to the brachioradialis. As this variation could potentially be confused with the medial or lateral antebrachial cutaneous nerves, it is important for the reconstructive surgeon to be aware of this to prevent inadvertent injury., (© 2019 S. Karger AG, Basel.)

Background: Single-stage latissimus dorsi neuromuscular transfer has been a valuable option for dynamic smile reanimation. However, there is a paucity of studies evaluating the potential donor morbidity in such cases. The present study aimed to comprehensively analyze the donor morbidity following functional latissimus dorsi muscle transfer., Methods: Patients who underwent single-stage functional latissimus dorsi muscle transfer for smile reanimation between 2002 and 2016 were reviewed. Postoperative complications and functional impairments at the donor sites were evaluated. The Quick-Disabilities of the Arm, Shoulder and Hand questionnaire was used for assessing postoperative donor-site function., Results: Sixty patients, including 12 pediatric (18 years or younger) patients, were analyzed. Mean length of a harvested thoracodorsal nerve was 14.9 cm. Fourteen patients were treated with a dual innervation technique, in which both a descending and a transverse branch of the thoracodorsal nerve were harvested. Donor complications were observed in seven cases; all of them were seromas and resolved by simple aspiration. No other complications including scoliosis and sensory and/or motor disturbances in the upper extremities were encountered. Fifty patients responded to the Quick-Disabilities of the Arm, Shoulder and Hand questionnaire at a median follow-up of 51 months. The average score was 2.64, and all but three patients scored less than 10. No variables, including patient age (pediatric versus adult) and the use of a dual-innervation technique, affected the donor morbidities, including the functional deficits., Conclusion: Single-stage latissimus dorsi neuromuscular transfer for facial reanimation might be associated with a low rate of complications and minimal functional morbidity at the donor site., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The reconstructive approach for incomplete facial paralysis is not yet determined. In this article, the authors present a new surgical approach for patients with incomplete facial paralysis in which residual, ineffective movement is detected preoperatively in the ipsilateral buccozygomatic territory of the paretic facial nerve., Methods: Sixteen patients with incomplete facial paralysis were found eligible for the procedure and underwent one-stage facial reanimation performed by the senior author (E.G.). Reanimation was performed using free gracilis muscle transfer with neural coaptation to an active facial nerve branch(es) responsible for the predetected buccozygomatic residual movement. Patients were reviewed in a systematic fashion using a combined still photographic and video scoring scale for symmetry at rest and at dynamic states., Results: Following surgery, improved symmetry was observed in the majority of observations of the mouth region at rest and while smiling and of the nasolabial fold region while smiling. There was no significant change in symmetry in the majority of observations of the eye region at rest and while smiling and the nasolabial fold region at rest. Video assessment of dynamic facial symmetry while smiling demonstrated improved symmetry in 91 percent of the observations (n = 191 observations). Comparison of mean scores for dynamic smile symmetry produced a statistically significant improvement of 1.68 points following surgery (p < 0.001)., Conclusion: Based on this series, the authors recommend that use of the ipsilateral facial nerve buccozygomatic residual branch be considered as a donor nerve for facial reanimation using a free gracilis muscle transfer in patients with incomplete facial paralysis with residual preoperative movement in the midface., Clinical Question/level of Evidence: Therapeutic, IV.

Abdominal flap phalloplasty is surgical construction of a neophallus using a pedicled abdominal flap for patients transitioning female to male, for males whose penis is congenitally absent, or lost from trauma. It is an option for trans men whose goals do not require urethroplasty or vaginectomy but would like a phallus suitable for male gender appearance. A prosthesis can be placed for penetrative sexual capability. Surgical text descriptions were enhanced by creation of new anatomic illustrations. Anatomy of donor site and surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. Significant structures of the donor site of the abdominal flap include the superficial external pudendal artery and ilioinguinal nerve that provide the blood supply and sensory innervation to the base of the flap, respectively. As a pedicled phalloplasty procedure, microsurgical anastomosis is not needed. Patients can expect to have tactile sensation but not innate rigidity. The dorsal nerve of clitoris (and sometimes the clitoris itself) is preserved to provide erogenous sensation. Abdominal flap phalloplasty makes it possible to maintain the natural blood supply and innervation to the neophallus. The neophallus created by abdominal flap phalloplasty has the advantage of homogeneous skin color and texture from contiguous skin. Grafting leaves a less stigmatizing horizontal scar running from one side of the pelvis to the other along the lower abdomen. The anatomy of the abdominal flap phalloplasty supports creation of a neophallus for transsexual anatomy revision. Clin. Anat. 31:181-186, 2018. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

The Free Fibula Osteoseptocutaneous flap is a reliable option when used in neophalloplastic procedures. It possesses intrinsic rigidity that is sufficient for penetrative intercourse, and satisfactory sensation. We review the pros and cons of this procedure, as well the anatomy and surgical steps involved. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites, as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The free fibula osteoseptocutaneous flap provides the neophallus with many desirable characteristics. Its thick subcutaneous and fascial layer, along with the thicker fibula (compared to the radius), allows for a neophallus of greater diameter. Skin marking, flap lifting, and transfer to the perineum with all relevant neurovascular anastomosis; fibular artery is anastomosed with the femoral artery, while the fibular veins are anastomosed to branches of the saphenous vein, as well as neurorrhaphy of the dorsal nerves of the clitoris and the LSCN are demonstrated. The osteomatized fibula is fixed to the periosteum of the pubic symphysis as shown. Anatomical traits of the Free Fibula Osteoseptocutaneous flap allow intercourse without prosthesis. The donor-site scar in this procedure can be covered by a long sock, and donor site morbidity is acceptable. Clin. Anat. 31:169-174, 2018. © 2018 Wiley Periodicals, Inc., (© 2018 Wiley Periodicals, Inc.)

Transgender surgeries are becoming more frequent and visual interpretation of anatomy is essential for both surgeons and patients. Since the forearm free flap phalloplasty was introduced in 1984, it has been known to provide reliable cosmetic and functional results for transitioning men compared with phalloplasty by different flaps. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. The forearm free flap consists of the anterior forearm skin, subcutaneous tissue, fascia containing the radial artery as the perforator and its venae comitantes, cephalic and basilic veins, and lateral and medial antebrachial cutaneous nerves are demonstrated in relation to the surgically derived flap. Song's forearm free flap phalloplasty requires two surgical stages with a three-month interval between the stages: prelamination of a neourethra and construction of a neophallus. The neophallus created by forearm flap phalloplasty is reported to achieve acceptable aesthetical and psychological satisfaction, appropriate size and shape, and satisfying sexual intercourse. Despite increasing experiences in gender confirming surgery with modifications made by many authors, urethral complications including fistula and/or stricture formation are the leading causes of reoperation. The poor esthetic outcome of the forearm donor site and a decrease in rigidity of the neophallus are the main limitations. Illustrations of anatomy help inform surgical choice and understanding of risks and benefits by patients. The anatomy of the free forearm flap phalloplasty supports creation of a neophallus for transsexual anatomy revision. Clin. Anat. 31:145-151, 2018. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Transgender reassignment surgeries have become a major topic of interest within the last decade. Although there are numerous surgical techniques for male-to-female reassignment, a physician must assess each patient's anatomy and past medical history to determine the most suitable technique. Additionally, patient preference is important. The neovaginal constructive technique most commonly used in male-to-female reassignment surgery is penile skin inversion, but various other techniques and tissues can also be used including pelvic peritoneum, buccal mucosa, and bowel. Surgical text descriptions were enhanced by creating new anatomical illustrations. Donor and recipient site anatomies, and the surgical technique leading to creation of the neovagina, are demonstrated in detail with relevant illustrations. A review of the literature concerning the anatomy, procedure development, and outcomes is presented. The pelvic peritoneum was originally used in neovaginal construction for females with vaginal agenesis as a result of MRKH syndrome. The use of this technique to create a neovagina in male-to-female transgender reassignment surgery has become appealing owing to the relative ease of the procedure, low complication rates, and overall high patient satisfaction. This technique offers a potential new choice for transgender male-to-female neovaginal construction, but further studies are needed to confirm its successful use in transgender surgery. Clin. Anat. 31:175-180, 2018. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: Defects in the weight-bearing heel or forefoot are commonly derived from chronic wounds, acute trauma, or tumor excision. Reconstruction of such defects pose a significant challenge to provide a flap that is stable, durable, and sensate. Several flaps have been described for reconstruction of plantar defects, but recurrent ulcerations and/or the need of additional procedures are common. This article provides the approach and outcomes of innervated free medial plantar flap for weight-bearing plantar defects reconstruction., Methods: Chart review was performed of 17 consecutive patients with defects in the weight-bearing heel and/or forefoot who were treated with innervated free medial plantar flaps between the years 1999 and 2016. Eleven patients were male, and 6 patients were female. The mean age was 29.5 years (range, 4-52 years). One case was combined heel/forefoot defect, 7 were heel defects, and 9 were forefoot defects. Indications were acute trauma, secondary reconstruction after trauma, and tumor excision., Results: The mean defect size was 8.0 ± 5.4 cm × 5.1 ± 2.1 cm, and mean flap size was 9.7 ± 1.4 cm × 6.4 ± 0.9 cm. One flap suffered from arterial thrombosis, which necessitated reoperation, and was salvaged. For the remaining cases, the postoperative course was uneventful. The mean follow-up time was 59.3 (±51.3.6) months. Two patients received minor flap corrections due to hyperkeratosis and hypertrophic scar, and 2 patients required donor site correction owing to partial loss of skin graft. One patient succumbed within 1 year owing to metastatic disease. All patients that were followed more than 1 year (n = 15) could sense blunt touch of the flap. Ten patients underwent 2-point discrimination test. No patient had recurrence of ulceration., Conclusions: The innervated medial plantar flap is an excellent solution for treatment of medium-to-large defects in the weight-bearing heel or forefoot. It provides glabrous skin that is stable, durable, and sensate. The long-term results are good, with no patient afflicted by recurrent ulceration during the follow-up time.

There is evidence that nerve flaps are superior to nerve grafts for bridging long nerve defects. Moreover, arterialized neurovenous flaps (ANVFs) have multiple potential advantages over traditional nerve flaps in this context. This paper describes a case of reconstruction of a long defect of the ulnar artery and nerve with an arterialized neurovenous free flap and presents a literature review on this subject. A 16-year-old boy sustained a stab wound injury to the medial aspect of the distal third of his right forearm. The patient was initially observed and treated at another institution where the patient was diagnosed with a flexor carpis ulnaris muscle and an ulnar artery section. The artery was ligated and the muscle was sutured. Four months later, the patient was referred to our institution with complaints of ulnar nerve damage, as well as hand pain and cold intolerance. Physical examination and ancillary tests supported the diagnosis of ulnar artery and nerve complete section. Surgery revealed an 8 cm hiatus of the ulnar artery and a 5 cm defect of the ulnar nerve. These gaps were bridged with a flow through ANVF containing the sural nerve and the lesser saphenous vein. The postoperative course was uneventful. Two years postoperatively, the patient had regained normal trophism and M5 strength in all previously paralyzed muscles according to the Medical Research Council Scale. Thermography revealed good perfusion in the right ulnar angiosome. The ANVF may be an expedite, safe and efficient option to reconstruct a long ulnar nerve and artery defect., (© 2017 The Authors. Microsurgery Published by Wiley Periodicals, Inc.)

Reconstructive surgery to the lips requires the replacement of defective tissues with similarly functioning tissues. While non-dynamic free tissue transfers provide adequate lower lip reconstruction, improved benefits may be obtained with innervated free muscle flaps. This study reports the use of innervated serratus anterior muscle free flaps for lip reconstruction in five patients. All patients had squamous cell carcinoma of either the upper or lower lip. After resection of the tumours, the resultant defects comprised two-thirds of the lips. The innervated serratus anterior muscle free flap was transferred to the lip and an end-to-end vascular anastomosis on the facial artery was performed. The marginal mandibular branch of the facial nerve was preferred for nerve coaptation. The inner and outer surfaces of the flaps were grafted with a split-thickness skin graft. Concentric needle electromyography of the orbicularis oris and frontal muscles was performed for all patients in the preoperative, postoperative, and follow-up periods. All patients survived the surgical operation. Three patients achieved perfect oral sphincter function without drooling. Electromyography at 1 year postoperative demonstrated the successful reinnervation of the serratus anterior muscle. This study demonstrates that lip reconstruction using an innervated serratus anterior muscle free flap is a reliable method, providing a functional lower lip., (Copyright © 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Radical tumor ablation in the periauricular area often results in extensive soft tissue defects, including facial nerve sacrifice, bone and/or dura defects. Reconstruction of these defects should aim at restoring facial reanimation, wound closure, and facial and neck contours. We present our experience using free anterolateral thigh flap (ALT) in combination with masseter nerve to facial nerve transfer in managing complex defects in the periauricular area., Methods: Between 2011 and 2015 six patients underwent a combined procedure of ALT flap reconstruction and masseter nerve transfer, to reconstruct extensive, post tumor resection, periauricular defects. The ALT flap was customized according to the defect. For smile restoration, the masseter nerve was transferred to the buccal branch of the facial nerve. If the facial nerve stump was preserved, interposition of nerve grafts to the zygomatic and frontal branches was performed to provide separate eye closure. The outcomes were analyzed by assessing wound closure, contour deformity, symmetry of the face, and facial nerve function., Results: There were no partial or total flap losses. Stable wound closure and adequate volume replacement in the neck was achieved in all cases, as well as good facial tonus and symmetry. The mean follow-up time of clinical outcomes was 16.8 months. Smile restoration was graded as good or excellent in four cases, moderate in one and fair in one., Conclusion: Extensive periauricular defects following oncologic resection could be adequately reconstructed in a combined procedure of free ALT flap and masseter nerve transfer to the facial nerve for smile restoration., (© 2016 Wiley Periodicals, Inc.)

Background: The immediate reconstruction of the face in the setting of radical parotidectomy for malignancy represents a particular challenge. We present a novel technique using 2 sections of the vastus lateralis muscle as a chimeric flap in combination with the anterolateral thigh (ALT) fasciocutaneous flap to achieve midface reanimation and eye closure after radical parotidectomy., Methods: The harvest technique in view of variations in chimeric muscle components, vascular pedicles, and neural coaptations is described herein., Results: On postoperative facial nerve examination, we observed encouraging results in middle-aged patients even in the context of radiotherapy., Conclusion: Although reanimation using the chimeric vastus lateralis free flap is yet to be objectively determined in a large series, our experience is that this flap adds the potential of dynamic midface movement and eye closure to our current reconstructive approach with excellent postoperative results in selected cases., (© 2017 Wiley Periodicals, Inc.)

Introduction: This study demonstrates the use of a modified free innervated DRAP flap utilizing the supermicrosurgery technique for fingertip reconstruction., Materials and Methods: From January 2010 to February 2014, 20 cases of fingertip reconstruction were performed using a short pedicle mini innervated transverse DRAP flap. The patients demographics, the mechanism of injury, the defect size and anatomical location, the source of pedicle vessels, the recipient vessels, the nerve branch used for innervation, the follow-up and sensation outcomes are reported. Three cases are presented demonstrating different anatomical fingertip injury reconstructions., Results: 20 consecutive traumatic fingertip injuries (M:F-14:6) were reconstructed with a free DRAP flap from the same hand. 6 index, 6 middle, 5 ring and 3 little finger defects were included in this study. All procedures were performed under regional anaesthesia and sedation. There were no intra- or post-operative complications. The average operative time was 105 (85-120) minutes. Each flap size was matching the size of the defects. All donor sites achieved primary closure and good cosmesis. The average follow-up was 12.8 (6-28) months. Follow-up demonstrated a static two-point discrimination of the flaps with an average distance of 5.5 (4-7) mm., Conclusion: The innervated DRAP flap has proven to be an easy, reliable and effective sensate fingertip reconstruction option, utilizing the supermicrosurgery technique., Level of Evidence: Level IV, retrospective series., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: With complete plexus injuries or late presentation, free functional muscle transfer (FFMT) becomes the primary option of functional restoration. Our purpose is to review cases over a 10-year period of free functioning gracilis muscle transfer after brachial plexus injury to evaluate the effect of different donor nerves used to reinnervate the FFMT on functional outcome., Methods: A retrospective study from April 2001 to January 2011 of a single surgeon's practice was undertaken. During this time period 22 patients underwent FFMT at Washington University in St Louis, Missouri for elbow flexion., Results: Thirteen patients for whom FFMT was performed for elbow flexion met all of the requirements for inclusion in this study. Average time from injury to first operation was 12.8 months (range 4-60), and average time from injury to FFMT was 29 months (range 8-68). Average follow-up was 31.8 months (range 11-84). The nerve donors utilized included the distal accessory nerve, intercostal with or without rectus abdominis nerves, medial pectoral nerves, thoracodorsal nerve, and flexor carpi ulnaris fascicle of ulnar nerve. Functional recovery of elbow flexion was measured using the MRC grading system which showed 1 M5/5, 5 M4, 4 M3, and 3 M2 outcomes., Conclusion: Intraplexal donor motor nerves if available will provide better transferred muscle function because they are higher quality donors closer to the muscle and can be done in one stage without a nerve graft. Otherwise, intercostal, rectus abdominis, or the distal accessory nerve should be used in a staged fashion. © 2016 Wiley Periodicals, Inc. Microsurgery 37:377-382, 2017., (© 2016 Wiley Periodicals, Inc.)

Background  The purpose of the present study was to evaluate arm and shoulder function prospectively after transfer of the lateral segment of the latissimus dorsi (LD) muscle. Methods  In this study, 20 specimens of LD muscles from 10 cadavers were dissected to determine the relationship between the artery and the nerve. Twenty patients were recruited and functional disability was determined by the Disabilities of Arm, Shoulder, and Hand (DASH), and muscle strength by needle electromyography (EMG) before surgery and at five different time points postoperatively. Results  Two specimens (10%) had no medial branch arising from the thoracodorsal artery. The pedicle length of the lateral branch was longer than that of the medial branch (mean 10.41 vs. 9.27 cm, p  = 0.03). All DASH scores and EMG amplitudes at half a month postoperative decreased compared with those preoperatively, with no significant difference at 3 months postoperative. Conclusion  Lateral segmental LD muscle transfer, leaving the residual segment motor function intact, can be recommended as an alternative for moderate and small-size bone exposure wounds, especially in the lower extremities, that minimizes loss of donor-site function., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Innervated free muscle transfer using the gracilis muscle or temporalis myoplasty has been successfully utilized for facial reanimation in chronic facial palsy. These techniques are less suited to immediate facial reconstruction in the setting of radical parotidectomy, in which the complexity of the defect, patient age, postoperative radiotherapy, and limited life expectancy pose particular challenges., Methods: We present a novel description of the use of a chimeric anterolateral thigh (ALT) flap and innervated vastus lateralis to achieve midface static suspension and dynamic reanimation in the setting of radical parotidectomy., Results: The technique is described in detail along with a video demonstrating the early and medium-term results in an example case., Conclusion: Although outcomes using the vastus lateralis free flap for midface reanimation need to be objectively determined, the flap adds the potential of dynamic midface movement in patients undergoing radical parotidectomy who would otherwise not be afforded this opportunity. © 2017 Wiley Periodicals, Inc. Head Neck 39: 602-604, 2017., (© 2017 Wiley Periodicals, Inc.)

Background: We describe a new dual neurorrhaphy method for a free abdominal-based flap and compare sensory recovery with this novel technique to that with conventional neurorrhaphy technique for breast reconstruction., Methods: 70 breast cancer patients underwent muscle sparing innervated transversal rectus abdominis myocutaneous flap (neuro ms-TRAM) breast reconstruction with either a novel dual neurorrhaphy technique (N = 41) or single (N = 29) neurorrhaphy only. Dual neurorrhaphy was performed on both sides and single neurorrhaphy on one side of the flap, using the end-to-end or end-to-side technique. Two years postoperatively, quantitative sensory testing (QST) was performed for tactile, and thermal sensory modalities, and other tests included sharp-blunt, vibration, and two-point discrimination. Sensory modalities were scored either zero (abnormal) or one point (normal) at each test site against normal reference values (five sites for most tests). The total sensory scores (TSC) were calculated on the basis of the sums of the individual test scores, and all data are presented as the median (interquartile range, IQR)., Results: The median of TSC in the breast reconstruction with the dual neurorrhaphy was higher (15.3, IQR 11.8-19.4), than that with the single neurorrhaphy (11.5, IQR 9.1-17.4) (P = 0.037). Regarding the different sensory modalities, the dual technique especially enhanced the tactile (P = 0.005) and cool detection (P = 0.021) recovery compared to the single neurorrhaphy., Conclusions: Dual neurorrhaphy improved the sensory recovery of the reconstructed breast, and may therefore be recommended for clinical practice. © 2014 Wiley Periodicals, Inc. Microsurgery 37:21-28, 2017., (© 2016 Wiley Periodicals, Inc.)

Introduction: Composite injuries of the volar surfaces of fingers are frequently associated with digital vessel and nerve damage. Flow-through glabrous flaps can provide esthetic tissue coverage as well as revascularization, and using a neurovascular flap, allows primary reconstruction of the digital nerve., Methods: Between June 2010 and August 2014, we prospectively studied the use of Microsurgical flow-through glabrous flaps to achieve simultaneously digital revascularization and soft tissue coverage in 13 fingers of 12 patients who experienced volar injuries, comprising 6 great toe fibular flaps, 3 medial plantar flaps, 1 pedis medialis flap, and 3 hypothenar flaps. The nerve passing through the great toe fibular flap or medial plantar flap was used to repair digital nerve defects., Results: All flaps survived completely. During a mean follow-up period of 13.6 months, the majority recovered excellent appearance and function. The flaps had the characteristics of normal finger volar skin: hairless, with similar texture and color. The mean static 2-point discrimination and Semmes-Weinstein monofilament scores of finger pulp were 4.8 and 3.03 mmin the great toe fibular flap group, 7.3 and 3.89 mm in the medial plantar flap group, and 7.5 and 3.84 mm in the sural nerve group., Conclusions: Glabrous flow-through flaps provide excellent reconstruction for fingers with volar injuries associated with digital vessel damage. The great toe fibular flap and the medial plantar flap are reliable and useful options for complicated finger injuries associated with digital vessel and nerve injuries.

Purpose: Gracilis muscle reinnervated by the contralateral facial nerve via cross-graft technique is nowadays considered to be a first-line procedure for facial animation in unilateral palsies. Despite the wide number of papers published analyzing technical aspects, refinements, functional results, and cosmetic outcomes, only a few authors have focused their publications on the patient's perspective and impact on QOL of these procedures., Material and Methods: Changes in quality of life in 42 patients treated with gracilis muscle transplant reinnervated via cross-face graft were analyzed through a comparison of preoperative and postoperative items on the Facial Disability Index questionnaire. Statistical evaluation with a paired t-test was performed concerning overall results and specific items modifications., Results: Overall improvement of QOL was found to be highly significant (p = 0.001). Mouth and eye functions were the most improved (p = 0.001), whereas isolation (p = 0.004) and feeling calm and peaceful (p = 0.001) were the most improved among the social functions., Conclusions: Facial animation with gracilis neuromuscular transplantation reinnervated with contralateral healthy facial nerve via a cross-graft procedure has been demonstrated to be a safe and reliable procedure in the treatment of congenital or established facial palsies. Our results on quality of life impact support that these operations are not only reliable and safe but also of primary relevance to patients' everyday lives., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Our aim was to compare the outcomes of reconstructive surgery for long-standing facial paralysis by gracilis free flap transfer versus lengthening temporalis myoplasty (LTM) according to Daniel Labbé., Materials and Methods: PubMed, Web of Science, Wiley Online Library, Cochrane Library, Directory of Open Access Journals, and SAGE Premier 2011 database were electronically searched. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), and case series with a sample size > 5 were sought. Data were extracted by a single investigator., Results: Sixteen articles met the selection criteria. All of these studies were retrospective case series. Efficacy outcomes were analyzed by assessing mouth symmetry both at rest and upon smiling, as well as the quality and the spontaneanity of the smile. Commissural displacement in patients operated by the gracilis flap was greater after surgery involving masseteric nerve reinnervation than a cross-facial nerve graft reinnervation. Patients with double innervation had similar results to those who had surgery involving only masseteric nerve reinnervation. These results are in accordance with the subjective evaluations. Patients operated by the lengthening temporalis myoplasty achieve less lateral movement of the commissure, with controversial evidence of spontaneity (only "automatic")., Conclusions: There are currently no published RCTs or CCTs regarding facial reanimation surgery. Thus, only very weak evidence is available to support the use of one type of surgery over another. However, our review suggests that LTM achieves results that are at least equal to those obtained with gracilis transfer, but LTM is a less extensive procedure that provides quicker results without the need for more than one operation. LTM, therefore, seems a good alternative to free muscle flap., Level of Evidence: IV., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The lateral arm free flap offers many advantages in reconstruction of soft tissue defect and reconstruction of extremities. However, this free flap is associated with sensory loss at the posterior forearm due to injury of the posterior antebrachial cutaneous nerve (PABCN).The PABCN-sparing lateral arm free flaps were performed in 19 patients with various soft tissue defects of the extremity, and the outcomes of free flap reconstructions using this modification are evaluated. All flaps survived without partial necrosis. Three patients experienced transient sensory loss in the posterior area of the forearm after flap harvest.In this study, lateral arm free flaps can be elevated without necessarily sacrificing the PABCN. This nerve-sparing modification decreases the donor-site morbidity of lateral arm free flaps and further increases the overall usefulness of this flap in soft tissue reconstructions of the extremities.

Background: Because of shearing forces, the forefoot is more prone to trophic ulcers than the heel. Reconstruction of trophic ulcers and other forefoot defects is a vexing challenge. We favor the innervated free medial plantar flap to replace like-with-like and confer protective sensation. We investigate the feasibility of this flap with the largest series to date and the first to describe ipsilateral flap transfer., Methods: Between 2009 and 2013, 7 patients with forefoot defects were treated with innervated free medial plantar flaps. The average age of 4 men and 3 women was 35.1 years (range, 8-50 years). Indications were secondary reconstruction after trauma and coverage of oncologic defects. The mean defect was 5 × 7 cm (range, 4-6 cm × 6-10 cm). Four patients were treated with contralateral flaps and 3 with ipsilateral flaps using interposition vein graft., Results: The mean flap size was 8.1 ± 1.6 cm × 5.9 ± 1.2 cm. There was no perioperative complication, venous congestion, or arterial insufficiency. Patients were followed clinically for 38.5 months (range, 6 months to 10 years). One patient died from complications of metastatic disease 7 months after plantar flap reconstruction. Two patients underwent sensory testing and gait analysis. The appearance was satisfactory, ambulation returned to normal, and there was protective sensation in every case. In 2 cases, hyperkeratotic tissue was excised in revision procedures., Conclusions: The innervated free medial plantar flap is an attractive and feasible option for coverage of medium-to-large defects of the plantar forefoot in the hands of a skilled microsurgeon. It has a place in our algorithmic approach to forefoot reconstruction.

Introduction: Complex heel injuries in children are rare and their management requires coverage combining resistance and thinness, to allow walking and footwear. The objective of this study was to create a decision-making algorithm for heel defect in children., Materials: Children received for heel defect, reconstructed with flap in our plastic surgery unit of Bordeaux with a follow-up greater than 10 years were investigated. Three children operated between 1999 and 2003 were included. A free contralateral reinnervated medial plantar flap, a free latissimus dorsi flap and a lateral supramalleolar flap were performed. Patients were reviewed in consultation to assess quality of reconstruction and functional outcomes. Three scores were used, the Foot Function Index (FFI), the AOFAS Ankle and Hindfoot Scale and the Maryland Foot Score., Results: No growth disorder has been found. Scores greater than 80 for the Maryland Foot Score and AOFAS Ankle and Hindfoot Scale and less than 10 for the FFI were very satisfactory in cases 1 and 3. We found pain and greater functional impairment in the second case., Conclusions: "Like-with-like" reconstruction remains the gold standard, whether in loco-regional or free flap. The fasciocutaneous flaps allow custom reliable coverage with little donor site morbidity. Loco-regional flaps remain easily accessible but donor site sequelae are not negligible., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Congenital diaphragmatic hernia is a severe developmental anomaly characterized by the malformation of the diaphragm. An innervated reversed latissimus dorsi flap reconstruction for recurrent congenital diaphragmatic hernia has been described as an alternative to prosthetic patch repair to achieve pleuroperitoneal separation. However, there is very little supporting scientific data; therefore, there is no real basic understanding of the condition of the phrenic nerve in the absence of diaphragmatic muscle or even the neurotization options for restoring neodiaphragmatic muscle motion. We have reviewed the literature regarding phrenic nerve anatomy and neurotization options, and to our knowledge, this is the first time that the application of a fascicular repair is being described where the continuity of one remaining fascicle of the diaphragm has been preserved close to the phrenic nerve distal division. The procedure was undertaken in a 3 year-old boy, with the diagnosis of congenital large posteromedial diaphragmatic hernia and dependence of mechanical ventilation in consequence of severe bronchopulmonary dysplasia.The phrenic nerve divides itself into several terminal branches, usually three, at the diaphragm level, or just above it. This allows the selective coaptation of separate fascicular branches. In the case described, videofluoroscopy evaluation showed no evidence of paradoxical neodiaphragmatic motion, with synchronous contraction movements and intact pleura-peritoneal separation. The child is now asymptomatic and shows improvement of his previous restrictive pulmonary disease.We believe that fascicular repair can achieve some reinnervation of the flap without jeopardizing the potential of diaphragmatic function by contraction of reminiscent native diaphragm.

Background: Tongue reconstruction after (hemi)glossectomy including sensory recovery is challenging. Although sensory recovery could improve functional outcome, no consensus on the need for reinnervation of the neo-tongue exists. Therefore, a systematic review was performed to determine if sensory reinnervation of free flaps in tongue reconstruction is better than no sensory reinnervation. The secondary study aim was to assess the effect of sensory reinnervation on overall functional outcome, such as speech and deglutition., Methods: Seven databases (Embase, Medline, Web of Science, Scopus, PubMed publisher, Cochrane, and Google Scholar) were searched. Studies that reported the effect of sensory reinnervation on overall functional outcome were identified., Results: Fourteen articles were included in the systematic review, concerning a total of 271 tongue reconstructions. Free flaps that were used were the radial forearm (RF) flap (n = 137), the anterolateral thigh (ALT) flap (n = 65), the rectus abdominis (RA) flap (n = 20), and the tensor fascia latae (TFL) flap (n = 5). Seven out of seven articles directly comparing sensory reinnervation with no sensory reinnervation revealed superior sensibility in the reinnervated group. Moreover, the innervated RF and ALT flaps showed superior recovery of sensibility compared to other flaps used for the reconstruction of hemiglossectomy as well as total glossectomy defects. There are indications that sensory reinnervation may have a beneficial effect on overall tongue function. Age, smoking, and sex did not affect sensory recovery. Four out of five articles showed that postoperative radiotherapy does not have a long-term adverse effect on sensory recovery., Conclusions: Sensory reinnervation of free flaps in the reconstruction of (hemi)glossectomy defects improves sensory recovery; however, evidence for beneficial effects on function is poor., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)